Changing paradigms in the surgical management of hyperparathyroidism at a tertiary care hospital in a developing country.

We report the presentation, management and outcomes of patients operated for hyperparathyroidism at our hospital. Patient sunder going surgery for hyper parathyroidism from 20 05 to 2 015 were retrospectively reviewed. Preoperative biochemistry, diagnostic scans and surgical procedures were studied. Follow up for cure rates, complications and histology were recorded. Out of 72 patients reviewed 54 (75%) were females and the rest males. The mean age was 48.04±15.5 years. Musculoskeletal complains were the most common (76.4%) among the cases reviewed. Asymptomatic hypercalcemia was seen in 13 (18.1%). The mean preoperative PTH level was 658.95 pg/ml and the mean preoperative calcium was 11.9 mg/dl. Bilateral neck exploration was done in 42 (58.3%) while focused unilateral approach was done in 27 (37.5%) cases. Solitary adenoma was the most frequent pathology in 58 (80.5%) patients. Asymptomatic hyperparathyroidism was less frequently detected in our population owing to lack of screening programme. Our patients are younger with a greater severity of the disease both symptomatically and biochemically compared to the West. In almost two decades, preoperative symptoms, calcium and PTH levels have changed marginally. Bilateral explorations are now giving way to focused less invasive procedures.

Clinical significance of prophylactic central compartment neck dissection in the treatment of clinically node-negative papillary thyroid cancer patients.

BACKGROUND: Lymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers. During the last decades, the role of routine central lymph node dissection (RCLD) in the treatment of papillary thyroid cancer (PTC) has been an object of research, and it is now still controversial. Nevertheless, many scientific societies and referral authors have definitely stated that even if in expert hands, RCLD is not associated to higher morbidity; it should be indicated only in selected cases. MAIN BODY: In order to better analyze the current role of prophylactic neck dissection in the surgical treatment of papillary thyroid cancers, an analysis of the most recent literature data was performed. Prophylactic or therapeutic lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, and papillary thyroid cancer were used by the authors as keywords performing a PubMed database research. Literature reviews, PTCs large clinical series and the most recent guidelines of different referral endocrine societies, inhering neck dissection for papillary thyroid cancers, were also specifically evaluated. A higher PTC incidence was nowadays reported in differentiated thyroid cancer (DTC) clinical series. In addition, ultrasound guided fine-needle aspiration citology allowed a more precocious diagnosis in the early phases of disease. The role of prophylactic neck dissection in papillary thyroid cancer management remains controversial especially regarding indications, approach, and surgical extension. Even if morbidity rates seem to be similar to those reported after total thyroidectomy alone, RCLD impact on local recurrence and long-term survival is still a matter of research. Nevertheless, only a selective use in high-risk cases is supported by more and more scientific data. CONCLUSIONS: In the last years, higher papillary thyroid cancer incidence and more precocious diagnoses were worldwide reported. Among endocrine and neck surgeons, there is agreement about indications to prophylactic treatment of node-negative "high-risk" patients. A recent trend toward RCLD avoiding radioactive treatment is still debated, but nevertheless, prophylactic dissections in low-risk cases should be avoided. Prospective randomized trials are needed to evaluate the benefits of different approaches and allow to drawn definitive conclusions.

The new era of robotic neck surgery: The universal application of the retroauricular approach.

Recent advances in technology has triggered the introduction of surgical robotics in the field of head and neck surgery and changed the landscape indefinitely. The advent of transoral robotic surgery and robotic thyroidectomy techniques has urged the extended applications of the robot to other neck surgeries including remote access surgeries. Based on earlier reports and our surgical experiences, this review will discuss in detail various robotic head and neck surgeries via retroauricular approach.

Reoperation Rates After Initial Thyroid Lobectomy for Patients with Thyroid Cancer: A National Cohort Study.

Introduction: The 2015 American Thyroid Association (ATA) guidelines recommended thyroid lobectomy (TL) as an alternative to total thyroidectomy (TT) for the surgical treatment of low-risk differentiated thyroid cancer. Increasing use of TL has since been reported despite concerns for an increased risk of disease recurrence and need for reoperation. This study sought to compare reoperation rates among patients who underwent initial TL or TT for malignancy, characterize trends at centers based on operative volume, and examine factors associated with reoperation. Methods: We queried the Vizient Clinical Data Base for TL and TT performed preguideline change (pre-GC = 2013-2015) and postguideline change (post-GC = 2016-2021). Reoperations included reoperative thyroid surgery (RTS) and neck dissection (ND); timing was defined as early (≤180 days), thought to indicate inadequacy of initial operative choice, or late (>180 days), suggesting potential disease recurrence. Results: Of 65,627 patients, 31.8% underwent initial TL and 68.2% underwent initial TT; TL increased from 21.4% of total cases pre-GC to 37.0% post-GC (p < 0.001). Among TL patients, early RTS declined from 33.9% to 14.2% and ND declined from 0.8% to 0.4% (p < 0.001). Among TT patients, early RTS remained 0.2%, while ND increased from 0.4% to 0.7% (p < 0.001). TL-associated late RTS declined from 2.0% to 1.7%, while ND increased from 0.6% to 0.8% (p = 0.17). In TT patients, both late RTS and ND increased, from 0.2% to 0.3% (p = 0.04) and 1.7% to 2.1% (p < 0.01), respectively. There was no difference in the late reoperation rate for TL compared with TT post-GC (+0.2%, p = 0.18). TL volume grew annually by 12.5% [8.9-16.2%] at high-volume centers (HVCs) and 8.3% [5.6-11.1%] at low-volume centers (LVCs). TL-associated reoperations at HVCs declined annually by 12.6% [5.6-19.0%] and 10.8% [2.7-18.1%] at LVCs. Uninsured status and more recent initial operation were associated with an increased risk of late reoperation (HR = 1.84 [1.06-3.20] and HR = 1.30 [1.24-1.36], respectively). The type of index operation performed, however, was not predictive of late reoperation. Conclusions: The rate of early reoperations declined for TL after the 2015 ATA guideline release, but late reoperations remained unchanged despite a significant shift in practice patterns towards initial lobectomy. Patients appear to be receiving less aggressive, guideline-concordant care without a significant increase in the late reoperation rate for TL compared with TT.

Trends and attitudes regarding head and neck oncologic surgery: a survey of United States oral and maxillofacial surgery programs.

PURPOSE: The purposes of this study were to: 1) estimate the prevalence and trends of American oral and maxillofacial surgery (OMS) programs in recruiting head and neck oncologic surgery (HNOS) -trained faculty, performing HNOS oncologic procedures and microvascular reconstruction, and presenting HNOS research at academic meetings; 2) estimate whether HNOS and microvascular reconstruction involvement varies among programs with or without a program director or chair trained in HNOS; 3) estimate whether HNOS involvement varies among those OMS programs that regularly attend and do not attend tumor board; 4) estimate whether HNOS involvement varies among those programs that have and have not presented HNOS research at an academic meeting; 5) estimate whether HNOS involvement varies among doctor of medicine-integrated and 4-year OMS programs. MATERIALS AND METHODS: Investigators developed and distributed a survey to all US OMS program directors and/or chair composed of questions regarding faculty prevalence and recruitment, frequency and trends in cases, and the priority of applicants for residency with regard to HNOS. There were 18 close-ended questions, and one open-ended question. Responses were recorded in categorical, Likert, ordinal, and numerical format. Bivariate associations were calculated using Fisher exact test and logistic regression. RESULTS: Sixty-three of 101 surveys were returned (62.3%). Ten program directors or chair completed a fellowship in HNOS (15.9%). Programs with an HNOS-trained program director or chair were more likely to have another HNOS-trained faculty member (P = .01), performed more malignant tumor resections (P < .001), neck dissections (P < .001), and microvascular free-flap reconstructions (P = .02) than programs without program directors or chair trained in HNOS. Programs that regularly attended tumor board performed an increasing number of malignant tumor resections (P = .008); and neck dissections (P = .003) than programs that did not regularly attend their institution's tumor board. Presentations of HNOS-related research at national meetings did not differ between doctor of medicine-integrated and 4-year OMS programs (P = .7). There was no difference in the prevalence of HNOS-trained program directors and chair between doctor of medicine-integrated and 4-year programs (P = .7). CONCLUSIONS: This study's data and comments suggest that programs involved in HNOS have a strong involvement in expanded scope OMS and related academic activities.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions.

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

[De-escalation strategies in differentiated thyroid cancer]. / Les stratégies de désescalade pour les cancers différenciés de la thyroïde.

Thyroid cancer runs the gamut from indolent micropapillary carcinoma to highly aggressive metastatic disease. Today, using prognostic algorithms, treatment and follow-up can be tailored to each patient in order to decrease overtreatment and over-medicalization of indolent disease. Active surveillance of papillary thyroid carcinoma less than 1cm avoids surgery and thyroid hormone replacement in a large proportion of patient whose tumors remain stable for years. Total thyroidectomy, once a dogma in the treatment of all thyroid cancer, is being supplanted by thyroid lobectomy for low-risk cancers, thereby decreasing the surgical risks involved and improving patients' quality of life. Indications for prophylactic central neck dissection, once mandatory, are now being adapted to the risk of cancer recurrence. Radioactive iodine therapy, also previously mandatory for all, is now only employed according to risk factors and expected outcomes. Follow-up is also being tailored to risk factors for recurrence, with less frequent visits and less use of ultrasound and scintigraphy. For more advanced disease, molecular therapies tailored to somatic mutations are opening opportunities for redifferentiation of aggressive tumors which become amenable to radioactive iodine therapy which carries fewer side effects than other systemic therapies. These advances in the management of thyroid cancer with a personalized approach and de-escalation of treatment and follow-up are improving the way we treat thyroid cancer, avoiding overtreatment and improving patients' quality of life.

Endoscopic Lateral Neck Dissection: A New Frontier in Endoscopic Thyroid Surgery.

Background: Endoscopic thyroidectomy and robotic thyroidectomy are effective and safe surgical options for thyroid surgery, with excellent cosmetic outcomes. However, in regard to lateral neck dissection (LND), much effort is required to alleviate cervical disfigurement derived from a long incision. Technologic innovations have allowed for endoscopic LND, without the need for extended cervical incisions and providing access to remote sites, including axillary, chest-breast, face-lift, transoral, and hybrid approaches. Methods: A comprehensive review of published literature was performed using the search terms "lateral neck dissection", "thyroid", and "endoscopy OR endoscopic OR endoscope OR robotic" in PubMed. Results: This review provides an overview of the current knowledge regarding endoscopic LND, and it specifically addresses the following points: 1) the surgical procedure, 2) the indications and contraindications, 3) the complications and surgical outcomes, and 4) the technical advantages and limitations. Robotic LND, totally endoscopic LND, and endoscope-assisted LND are separately discussed. Conclusions: Endoscopic LND is a feasible and safe technique in terms of complete resection of the selected neck levels, complications, and cosmetic outcomes. However, it is recommended to strictly select criteria when expanding the population of eligible patients. A formal indication for endoscopic LND has not yet been established. Thus, a well-designed, multicenter study with a large cohort is necessary to confirm the feasibility, long-term outcomes, oncological safety, and influence of endoscopic LND on patient quality of life (QoL).

Multicenter retrospective analysis of clinicopathological features and prognosis of oral tongue squamous cell carcinoma in adolescent and young adult patients.

ABSTRACT: The aim of this study is to report the differences in clinicopathological features of oral tongue squamous cell carcinoma (OTSCC) and survival between adolescent and young adult (AYA) patients and elderly patients and to find the prognosticators. The medical records of 101 AYA patients and 175 control patients with OTSCC who underwent surgery were reviewed. Variables related to prognosis and their clinicopathological associations were analyzed. The 5-year overall survival (5y-OS) rates of AYA and control patients with stage I and II OTSCC were 94.4% and 89.6% (P = .353), respectively, and their 5-year disease-free survival (5y-DFS) rates were 82.0% and 76.6%, respectively (P = .476). The 5y-OS rates of patients with stages III and IV OTSCC were 83.3% and 66.7% (P = .333), respectively, and their 5y-DFS rates were 75.0% and 57.1% (P = .335), respectively. Logistic regression analysis revealed that there was no significant clinicopathological difference in AYA and control group. Furthermore, there was no significant difference in 5y-OS rates between patients who underwent elective neck dissection (END) and those who underwent therapeutic neck dissection (TND) in both group (P = 0.717 and 0.688). Overall, the present study revealed the clinicopathological features and prognosis of OTSCC were similar in AYA patients and elderly patients. Moreover, as there was no significant difference in OS between patients who underwent END and those who underwent TND in AYA and control groups, our results suggest that the indication for END in AYA patients with clinical N0 OTSCC is similar to that for elderly patients.

Neck dissection: past and present.

The presence of lymph node metastasis to the neck is accepted as one of the single most important adverse prognostic indicators of survival in squamous cell carcinoma of the head and neck. Neck dissection in its various forms is the standard surgical treatment for clinical and subclinical metastatic cancer to the neck. This paper is a review of the anatomy of the neck, history and specific types of neck dissection, indications, therapeutic options, and current challenges in the treatment of metastatic neck disease.

Prophylactic lymph node dissection in clinically N0 differentiated thyroid carcinoma: example of personalized treatment.

Considering the 'differentiated thyroid carcinoma (DTC) epidemic', the indolent nature of DTC imposes a treatment paradigm shift toward elimination of recurrence. Lymph node metastases in cervical compartments, encountered in 20-90% of DTC, are the main culprit of recurrent disease, affecting 5-30% of patients. Personalized risk-stratified cervical prophylactic lymph node dissection (PLND) at initial thyroidectomy in DTC with no clinical, sonographic or intraoperative evidence of lymph node metastases (clinically N0) has been advocated, though not unanimously. The present review dissects the controversy over PLND. Weighing the benefit yielded from PLND up against the PLND-related morbidity is so far hampered by the inconsistent profit yielded by PLND and the challenging patient selection. Advances in tailoring PLND are anticipated to empower optimal patient care.

Selective Neck Dissection Guided by a Radioactive I125 Seed for Papillary Thyroid Carcinoma Recurrence. / Disección cervical radioguiada con semillas de I125 como tratamiento de la recurrencia de cáncer papilar de tiroides.

Lymph nodes are the most common place of recurrence of papillary thyroid cancer, and surgery can be considered a therapeutic option. The risks of surgery increase with every intervention. We present 3 cases of cervical non palpable thyroid cancer recurrence managed with I125 seed radioguided cervical dissection from 2017 to 2019. Two of the cases had already a thyroidectomy and central compartment lymphadenectomy performed. The seed was placed guided by US on the lesion and its position was confirmed afterwards. The target was successfully localized in 100% of cases. There was no post surgery complications. There was no evidence of recurrence with a mean follow up of 15 months. Radioguided surgery using I125 seed it is a save technique and it offers a precise localization of the non palpable thyroid cancer recurrence.

Elective neck dissection in oral squamous cell carcinoma: Past, present and future.

In 1994 a decision analysis, based on the literature and utility ratings for outcome by a panel of experienced head and neck physicians, was presented which showed a threshold probability of occult metastases of 20% to recommend elective treatment of the neck. It was stated that recommendations for the management of the cN0 neck are not immutable and should be reconfigured to determine the optimal management based on different sets of underlying assumptions. Although much has changed and is published in the almost 25 years after its publication, up to date this figure is still mentioned in the context of decisions on treatment of the clinically negative (cN0) neck. Therefore, we critically reviewed the developments in diagnostics and therapy and modeling approaches in the context of decisions on treatment of the cN0 neck. However, the results of studies on treatment of the cN0 neck cannot be translated to other settings due to significant differences in relevant variables such as population, culture, diagnostic work-up, follow-up, costs, institutional preferences and other factors. Moreover, patients may have personal preferences and may weigh oncologic outcomes versus morbidity and quality of life differently. Therefore, instead of trying to establish "the" best strategy for the cN0 neck or "the" optimal cut-off point for elective neck treatment, the approach to optimize the management of the cN0 neck would be to develop and implement models and decision support systems that can serve to optimize choices depending on individual, institutional, population and other relevant variables.

Association of Insurance Expansion With Surgical Management of Thyroid Cancer.

IMPORTANCE: To our knowledge, thyroid cancer incidence is increasing faster than any other cancer type and is currently the fifth most common cancer among women. While this rise is likely multifactorial, there has been scarce consideration of the effect of insurance statuses on the treatment of thyroid cancer. OBJECTIVE: We evaluate the association of insurance expansion with thyroid cancer treatment using the 2006 Massachusetts health reform, which serves as a unique natural experiment. DESIGN, SETTING, AND PARTICIPANTS: We used the Agency for Healthcare Research and Quality State Inpatient Databases to identify patients with government-subsidized or self-pay insurance or private insurance who were admitted to a hospital with thyroid cancer and underwent a thyroidectomy between 2001 and 2011 in Massachusetts (n = 8534) and 3 control states (n = 48 047). Difference-in-differences models were used to evaluate an association between the 2006 Massachusetts health care reform and thyroid cancer treatment, and participants were controlled for age, sex, comorbidities, and secular trends. MAIN OUTCOMES AND MEASURES: Change in the thyroidectomy rate for thyroid cancer treatment was the primary outcome evaluated. RESULTS: The Massachusetts cohort consisted of 6443 women (75.5%) and 2091 men (24.5%), of whom 6388 (79.6%) were white, 391 (4.9%) were black, 527 (6.6%) were Hispanic, 424 (5.3%) were Asian/Pacific Islander, 63 (0.8%) were Native American, and 228 (2.8%) were other. The participants from control states included 36 818 women (76.6%) and 11 229 men (23.4%), of whom 30 432 (65.5%) were white, 3818 (8.2%) were black, 6462 (13.9%) were Hispanic, 2591 (5.6%) were Asian/Pacific Islander, 211 (0.5%) were Native American, and 2947 (6.3%) were other. Before the 2006 Massachusetts insurance expansion, patients with government-subsidized or self-pay insurance had lower thyroidectomy rates for thyroid cancer in Massachusetts and the control states compared with patients with private insurance. The Massachusetts insurance expansion was associated with a 26% increased rate of undergoing a thyroidectomy (incident rate ratio, 1.26; 95% CI, 1.04-1.52; P = .02) and a 22% increased rate of neck dissection (incident rate ratio, 1.22; 95% CI, 1.07-1.37; P = .002) for treating cancer compared with control states. CONCLUSIONS AND RELEVANCE: The 2006 Massachusetts health reform, which is a model for the Affordable Care Act, was associated with a 26% increased rate of thyroidectomy for treating thyroid cancer. Our study suggests that insurance expansion may be associated with increased access to the surgical management of thyroid cancer. Further studies need to be conducted to evaluate the effect of healthcare expansion at a national level.

Trends and the utilization of transoral robotic surgery with neck dissection in New York State.

OBJECTIVES: The timing of neck dissection (ND) in relation to transoral robotic surgery (TORS) is controversial. This study identifies local practice patterns and economic and social access disparities during adoption of TORS. STUDY DESIGN: We analyzed utilization patterns of TORS and ND using the New York Statewide Planning and Research Cooperative System all-payer administrative database. Statewide head and neck cancer incidence from the Centers for Disease Control and Prevention (Bethesda, MD) was used to control for overall cancer incidence. METHODS: Patient demographic, insurer, and institutional information of patients aged ≥ 18 (n = 225) years from 2008 to 2012 were evaluated. Temporal trends were analyzed with Poisson regression models for counts. RESULTS: Transoral robotic surgery was used in 386 procedures, and 58.3% involved ND (n = 225). Concurrent ND was most frequent (n = 173), followed by staged TORS then ND (n = 44) and staged ND preceding TORS (n = 8). Caucasians were more likely than Blacks/Hispanics to undergo TORS (P = 0.03). Medicare (26.2%) and Medicaid (2.7%) payers comprised a minority of patients compared to those commercially insured (70.2%). Only 20% of patients received care outside a major urban center, and these patients were more likely to undergo staged procedures, P = 0.02. Staged procedures resulted in higher mean hospital charges (P = 0.02). CONCLUSION: Concurrent TORS + ND, the most common practice in New York, is more cost-effective. Patients without commercial insurance, patients in racial minorities, or patients residing outside major urban centers may be targeted to improve care access disparities with respect to minimally invasive TORS technology. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1571-1576, 2017.

Neck dissection: then and now.

The significance of metastatic disease in the lymph nodes of the neck as a critical independent prognostic factor in head and neck cancer has long been appreciated. Although 19th century surgeons attempted to remove involved cervical lymph nodes at the time of resection of the primary cancer, a systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdynski in 1888 and popularized and illustrated by Crile in the early 20th century, provided consistent and more effective treatment, and forms the basis of our current techniques. During the first half of the 20th century, developments included preservation of the accessory nerve in selected cases, elective neck dissection performed in association with resection of various primary tumors, bilateral neck dissection and limited neck dissection. The greatest impetus to the status of radical neck dissection came from Martin, whose technique consisted of resection of all lymph nodes from level I-V together with the accessory nerve, internal jugular vein, sternocleidomastoid muscle and various other structures in a single block of resected tissue. Martin's technical precepts were followed until the latter part of the 20th century when modifications in technique began to find general acceptance. The first description of an effective technique of modified radical neck dissection was published in Spanish by Suárez, in 1963. This technique, which preserves important structures, such as the internal jugular vein, sternocleidomastoid muscle and accessory nerve, was refined and popularized by various authors who published their results in the English language literature during the period from 1964 through 1990 and beyond. Modified or "functional" neck dissection avoids much of the morbidity of radical neck dissection while achieving equivalent degrees of control of regional disease in properly selected cases. By the late 20th century, the concept of selective neck dissection, consisting of resection of only the nodal groups at greatest risk for metastasis from a given primary site, was studied and developed. These limited dissections are now widely employed for elective, and in properly selected cases, therapeutic treatment and staging of the neck, and have been proposed for limited cervical recurrences after various chemoradiation protocols. Prospective studies have demonstrated similar rates of neck recurrence and survival after elective selective neck dissection compared to elective modified radical neck dissection. Other modifications and factors applied to treatment of cervical lymph node disease include the use of adjuvant and neo-adjuvant radiation and chemotherapy, a revised system for classification of neck dissections, the identification of various adverse prognostic factors such as extracapsular spread and extranodal soft tissue deposits, application of sentinel lymph node biopsy to staging of the neck, the use of immunohistochemical and molecular techniques for identification of lymph node metastases not detectable by light microscopy, and the possibility of endoscopic neck dissection. The authors conclude that neck dissection, as evolved over the past century, is a fundamental tool in management of patients with head and neck cancer, but is still a work in progress.

Neck dissection: past, present and future?

With the exception of distant metastasis, the presence of cervical lymph node metastasis is the single most adverse independent prognostic factor in head and neck squamous cell carcinoma. Surgical removal of metastatic cervical lymph nodes had been attempted during the late nineteenth century, with varying techniques and poor results. A systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdynski at the end of the nineteenth century and popularized and illustrated by Crile in the early twentieth century, provided consistent and more effective treatment and forms the basis of our current techniques. The concepts of radical neck dissection, employed extensively by Martin, were followed with almost religious consistency by most head and neck surgeons until the late twentieth century, when the principles of 'functional' neck dissection, developed by Suárez and popularized by Bocca, Gavilán, Ballantyne, Byers and others, led to the acceptance of modified radical neck dissection as treatment for lymph node disease in various stages. More recently, selective neck dissection, involving removal of nodes confined to the levels at greatest risk of metastasis from primary tumours at various sites, has become accepted practice for elective and, in some instances, therapeutic treatment of the neck. In the future, sentinel lymph node biopsy and the use of molecular pathological analyses may be employed to predict the presence of occult cervical disease, thus directing therapy to patients at greatest risk and sparing those without regional metastasis.

Parotidectomy: surgery in evolution.

BACKGROUND: Approximately 15 years ago, Bron and O'Brien described a large Australian series of 248 patients focusing on facial nerve function post parotidectomy performed by a single surgeon over an 8-year period. The primary aim of this study was to assess changes in pathology, surgical approach and outcomes following parotidectomy in a comparable single surgeon series from the same institution. METHODS: Details of patients undergoing parotidectomy by, or under the supervision of, the senior author (JRC) between February 2006 and December 2013 were retrospectively reviewed. Operative reports and post-operative complications were recorded using standardized templates. Comparison with the Bron and O'Brien outcomes is presented. RESULTS: A total of 405 consecutive parotidectomies were performed for both benign and malignant disease in 401 patients. Univariable predictors of facial nerve weakness (temporary or permanent) on logistic regression were neck dissection (odds ratio 2.1, 95% confidence interval (CI) 1.23-3.67, P = 0.007) and operation type, with focused tumour dissection having 0.07 times the odds (95% CI 0.01-0.52, P = 0.010) and a limited parotidectomy approach having 0.5 times the odds (95% CI 0.26-0.91, P = 0.024) of facial palsy compared with a complete superficial parotidectomy. CONCLUSION: A number of changes in the management of parotid pathology in Australia have occurred in the last two decades, including improvements in the characterization of malignant parotid tumours, a continuing evolution towards less aggressive surgery, a more selective approach to elective neck dissection and an increasing appreciation of the techniques that can be used to minimize the aesthetic complications of parotid surgery.

Neck dissection: cause and effect.

OBJECTIVE: This study aimed to evaluate changes in neck dissection procedures over time in a tertiary university hospital to determine their influence on residency training. METHODS: Neck dissections performed in a recent decade (2003-2012) were retrospectively analysed and compared with those of an earlier decade (1981-1990). RESULTS: Nowadays, neck dissections are most frequently performed for thyroid (2003-2012 vs 1981-1990: 60.7 per cent vs 25 per cent, p = 0.002) and less often for epithelial malignancies (23.2 per cent vs 53.5 per cent, p = 0.002). Compared with dissections for thyroid spread, more dissections for epithelial malignancies are extensive (epithelial vs thyroid malignancies, 66 per cent vs 4.9 per cent) and more are performed after chemoradiation failures (25.6 per cent vs 0 per cent). CONCLUSION: This study demonstrates changes in neck dissection procedures over time. There is an increasing preference for conservative treatment for epithelial cancers. In addition, there is a large increase in both the diagnosis and surgical treatment of thyroid cancer. This shift may have a great effect on residents' learning curves and on their ability to achieve competency in performing neck dissections.

Neck dissection: current concepts and future directions.

For individuals diagnosed with head and neck cancer, neck dissection may be performed for therapy or disease staging. The classification of neck dissection and the definition of precise anatomic landmarks have allowed for this operation, and its many variations, to become standardized world-wide. SLNBX shows promise in its ability to accurately stage NO head and neck cancer and may allow patients with no micro metastatic disease to avoid neck dissection. Before this technique becomes adopted into routine clinical practice, however, it must first be prospectively scrutinized in large patient populations. Regardless of the future role of SLNBX in the management of head and neck cancer, currently it is only through a complete understanding of the clinical, theoretic, and technical aspects of neck dis-section that surgeons may benefit individual patients and the head and neck cancer patient population as a whole.